Provider Demographics
NPI:1780662411
Name:KOONTZ, STANLEY E JR (MD)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:E
Last Name:KOONTZ
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1174 COOL SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:ERNUL
Mailing Address - State:NC
Mailing Address - Zip Code:28527-9413
Mailing Address - Country:US
Mailing Address - Phone:252-244-0729
Mailing Address - Fax:
Practice Address - Street 1:800 HOSPITAL DR
Practice Address - Street 2:SUITE # 1
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28560-3410
Practice Address - Country:US
Practice Address - Phone:252-633-8119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.086533207P00000X
NC2006-01265207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2583717Medicaid
OH0056419Medicaid